TRADITIONAL, NOT CONVENTIONAL.

Why He Hopes to Die at 75 (January 26, 2016)

My previous newsletter shed a little light (or so I hope) on the often-murky subject of detoxification. It was not the most popular thing I’ve ever written. I suspect that today's newsletter, about someone's decision to avoid any but palliative medical care after age 75, will be even less so. Well, so it goes.

I went with this topic today (although I have been considering it for a while) because of a recent study which found that in the six-month period before death, doctors receive less aggressive medical care than does the general population. ("Less aggressive" meaning fewer surgeries and less hospitalization.) In other words, something DIFFERENT than what their patients are getting. The reason for their choice is given to be that “Doctors understand modern medicine can both help and harm people, especially at the end of life, and they understand its limits.”

Ah, the limits of medical care. Those limits are a lot more, um, limited than your average person realizes. Anyone who has had a medical procedure that did not turn out as planned has an idea of what that means. But the debility and physical problems that tend to accompany advancing age can make even successful medical treatment much harder to tolerate, reduce any benefits and make the whole deal much more personally costly.

That study reminded me of an article that 58-year-old Dr. Ezekiel Emanuel (yes, one of THOSE Emanuels) wrote a little over a year ago, setting forth his intention to refuse all but palliative medical care after he reaches 75 and the reasons for same. He stated that as a consequence of that decision he expects to live fewer years than if he took the usual route, but he expects that those years will be of better quality and considers that to be a fair trade. If you have not read Dr. Emanuel’s original article, and think that you might die sometime, you really should do so. You can find it here:

Dr. Emanuel rather bluntly asserts that most people have lived the best part of their lives and made their most meaningful contributions by age 75, and that the treatment of disorders past that age at best just tacks a few relatively unproductive and often pain- and disability-filled years on at the end of it. He states that such care is costly, and takes money that could be better spent improving the health of younger people, who have more years to experience any benefits.

He continues with how he would like his survivors to remember him as a hale and active person rather than with the limitations of age and disability, and how he wants to minimize the chances of becoming a resented chore rather than an active participant in their lives. In short, Dr. Emanuel spends a good deal of his article enumerating the reasons he thinks life after 75 is nothing to get excited about. When you see those reasons all listed out at once, they are quite impressive, although not enough to automatically make you want to take out the house pistol.

He doesn’t cover every possible consequence of his decision, and it’s not clear whether that is because he has not thought it out or is just in the interests of brevity. And I certainly don’t agree with everything he says. But as an M.D. he is indeed one of those who, like the ones I first discussed, understands the limits of medicine. His list of reasons as to why he determines to avoid anything but palliative medical care after 75 is his way of telling laypeople that treatment isn't worth it to him -- without ever directly discussing those limits.

He's so busy killing sacred cows that he misses the elephant in the room. And that elephant is that his proposal is not only the best way to live as healthy (albeit slightly shorter) an old age as possible -- it is also a great way to live the life you have before you get there.

Dr. Emanuel doesn't really tell us that the older you get, the harder it is to bounce back from the consequences of even the best medical care, the less benefit you can derive from those procedures, and the more likely you are to suffer harm from them. Past a certain point, more medical intervention just means more misery. But most medical interventions come with a price at any time.

Age aside, most heroic medical care ain’t what it’s cracked up to be. It’s amazing how many treatments and procedures provide minimal benefit, or no benefit at all, to most of the people treated. (The key term there is "NNT", or "number needed to treat" -- how many people who receive a treatment will actually see benefit from it? It's lower than you think for even many common treatments and is worth asking about any time you're faced with the possibility of something medical you don't like the sound of.)

A 40-year-old might want to take the chance of a joint replacement with all its attendant risks if the alternative is decades of pain from a seriously damaged joint. But a 65-year-old -- or an 80-year-old? Maybe not. The downsides increase, and the upsides diminish, the farther down the road you've gone. But they are not small at any stage, and should never be taken lightly. We live longer than previous generations but we are MORE likely to be disabled or impaired than they were. So this will be a real issue for everyone, at some time or other, who is lucky enough to get old.

I couldn't help but think of my mom as I read this. Her many medications enabled her to live independently until age 89, when she had a massive stroke and spent the last year of her life paralyzed in a wheelchair, unable to speak a coherent sentence and unable to swallow anything that wasn’t pureed.

My mom’s chiropractor also came to mind. He continued to practice as a chiropractor, and one respected enough to receive regular referrals from Mt. Sinai Medical Center in New York City, up until he died at age 94. The week before his death, one of my family members saw him out on the local course playing golf. He had had Parkinson’s disease for many years, and he had the very restricted gait and rest tremor that characterizes that disease. He would hit the ball, it would go about ten feet, and he would shuffle up after it and hit it again, clearly having a great time.

"One size fits all", then, certainly is not an expression that applies to medical care for anyone of any age. There are no guarantees. The best laid plans of mice and men. Etc. But whatever our decision on this, at one time or another, we all ought to really, really think about it, and try not to be swayed by either fear or wishful thinking.